Ketelhut, Sascha Institute of Sport Science, University of Bern, Bremgartenstrasse 145, 3012, Bern, Switzerland
Brand, Ralf;Hug, Daniel;Mueller, Florian ‘Floyd’ et al

Sports Medicine – Open,10/15/2025

Maximal exercise testing is a fundamental component of sports medicine and clinical practice, essential for evaluating physical fitness, tailoring training programs, and diagnosing health conditions. A crucial aspect of maximal exercise testing is ensuring that participants exert maximal effort, as insufficient effort can compromise the validity of results, potentially leading to misdiagnoses, misinterpretation of outcomes, and inappropriate exercise recommendations. Various strategies, including verbal, audio, and video-based methods, have been used in research and practice to encourage maximal effort. Despite the recognized importance of these strategies, understanding of them remains limited, with recommendations being either inconsistent or entirely lacking. Notably, innovative approaches that harness the potential of digital methods are still relatively scarce. In this article, we discuss the potential of incorporating game elements as an innovative encouragement strategy during maximal exercise testing. Drawing from research on exergaming, we provide examples of impactful game features and discuss their potential integration into exercise testing. This innovative approach has the potential to improve test reliability, enhance validity, streamline workflows, and positively influence attitudes toward exercise testing. We advocate for establishing a new area of research focused on gamifying maximal exercise tests to elevate exercise diagnostics to the next level. Key Points: • Maximal exercise testing is an important tool for assessing physical fitness and diagnosing health conditions. A critical factor in ensuring the validity of these tests is confirming that participants exert maximal effort, which can be particularly challenging in certain target groups. • Currently, verbal encouragement is predominantly used in research and practice. However, this is difficult to standardize and often lacks engagement, as it heavily depends on the individual delivering it. Game design elements may offer a more effective approach by fostering a dissociative focus, enhancing motivation, and increasing effort investment. • Immersive and engaging game design elements used as encouragement strategies may improve the validity of maximal exercise tests and enhance compliance, especially in populations with lower motivation.

Walters GWM, Leicester Biomedical Research Centre, Leicester LE3 9QP, UK
Gulsin GS, Henson J, Argyridou S, Parke KS, Yates T, Davies MJ, McCann GP, Brady EM.

J Funct Morphol Kinesiol. 2025 Sep 26;10(4):371.

Purpose: While peak oxygen uptake (V.O2peak) is the gold standard method for assessing exercise tolerance, there is a tendency for underestimation. Several other cardiopulmonary exercise testing (CPET) variables may provide additive prognostic value beyond V.O2peak alone. The aim of this study was to examine if alternative CPET indices of exercise tolerance are (a) impaired in people with T2D and (b) independently associated with measures of cardiovascular structure and function measured via echocardiography and cardiac MRI.
Methods: Participants with type 2 diabetes (T2D) and healthy controls underwent cardiac magnetic resonance imaging, transthoracic echocardiography, and a CPET. Multiple linear regression was used to determine the relationship between indices of exercise tolerance and markers of cardiovascular structure and function.
Results: A total of 84 people with T2D and 36 healthy volunteers were included in the analysis. All CPET outcomes were worse in those with T2D vs. the controls. Three CPET outcomes were associated with markers of cardiovascular structure and function: V.O2 recovery with mean aortic distensibility (β = 0.218, p = 0.049); heart rate recovery with early filling velocity on transmitral Doppler/early relaxation velocity (β = -0.270, p = 0.024), left ventricular mass/volume ratio (β = -0.248, p = 0.030) and mean aortic distensibility (β = 0.222, p = 0.029); and V.O2 at the ventilatory threshold with myocardial perfusion reserve (β = 0.273, p = 0.018).
Perspective: These lesser-used CPET indices could be used to identify which people with T2D are at elevated risk of progression to symptomatic heart failure. However, larger longitudinal studies are required to confirm these findings and their potential clinical application.

Randy H; Université Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France.
Perrin TP; Ghaith A; Kohlbrenner D; Flore P; Champigneulle B; Guinot M; Doutreleau S;
Brugniaux J;Verges S;Marillier

Physiological reports [Physiol Rep] 2025 Oct; Vol. 13 (19), pp. e70432.

Vascular aging involves reduced endothelial function, a key factor in cardiovascular diseases. Intermittent hypoxia may improve endothelial function and cardiorespiratory fitness (CRF), but its effects in elderly individuals, especially in the mid-term, have not yet been studied. This randomized, single-blind controlled trial aimed to investigate whether an 8-week intermittent hypoxic conditioning (IHC) program may enhance flow-mediated dilation (FMD) and CRF in elderly individuals. Twenty-six participants (60-80 year-old) were assigned to either the IHC (n = 12) or the control group (CTL: n = 14). The IHC group underwent 24 passive intermittent hypoxia sessions (3/week). Brachial artery FMD, cardiopulmonary exercise testing (CPET), and ambulatory 24-h blood pressure were assessed at baseline (Pre), immediately post-intervention (Post 1), and 2 months later (Post 2). FMD showed a trend toward improvement in the IHC group, being significant when normalized for baseline artery diameter (p = 0.023; η _p²  = 0.150) between Pre and Post 2. Peak ventilation during CPET increased from Pre to Post 1 (p = 0.021), with no other significant CRF changes. Daytime systolic blood pressure decreased by 6 mmHg (p = 0.070, η _p²  = 0.105). No significant alterations in these outcomes were observed in the CTL group (p > 0.05). Moderate IHC enhanced mid-term endothelial function, suggesting potential to mitigate age-related vascular decline.

 Magrì, Damiano; Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
Fiori, Emiliano; Agostoni, Piergiuseppe; Correale, Michele ;et al;

Heart failure reviews [Heart Fail Rev] 2025 Oct 07.
Date of Electronic Publication: 2025 Oct 07.

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) frequently coexist and interact through complex and bidirectional hemodynamic mechanisms that amplify symptoms’ burden and complicate clinical management. The present review explores the impact of COPD across the HF spectrum, particularly in HF with preserved ejection fraction (HFpEF), where comorbidities, such as COPD, exert a dominant role in disease expression. COPD-induced hyperinflation reduces cardiac preload and increases right ventricular afterload, while HF-related congestion impairs pulmonary function and gas exchange, illustrating a tight cardiorespiratory coupling. Diagnostic challenges stem from overlapping symptoms and the limited specificity of biomarkers, such as natriuretic peptides, especially in HFpEF. Cardiopulmonary exercise testing (CPET) emerges as a valuable tool for distinguishing between cardiac and pulmonary limitations and guiding individualized treatment strategies. From a therapeutic standpoint, β1-selective blockers are not only safe in COPD patients but are pivotal in those with HF with reduced ejection fraction (HFrEF), where they have been demonstrated to improve survival and reduce both HF and COPD exacerbations. Concerns regarding bronchodilator safety in HF remain largely theoretical, with current evidence supporting their continued use when clinically indicated. Ultimately, optimal care for patients with coexisting COPD and HF requires a phenotype-specific approach, incorporating insights from pathophysiology, diagnostic innovation, and evidence-based pharmacotherapy to improve outcomes in this challenging patient population.

Hogwood, Austin C.; University of Virginia, Charlottesville, VA. USA
Golino, Michele; Canada, Justin M.; West, Joshua; et al;

Medicine & Science in Sports & Exercise; (Baltimore, Maryland) 2025Supplement; v.57, 511-512. (2p)

The article focuses on the relationship between cardiac reserve and cardiorespiratory fitness (CRF) in patients who have experienced reperfused ST-elevation myocardial infarction (STEMI). A study involving fifty-six patients assessed cardiac reserve through Doppler echocardiography and CRF via a symptom-limited cardiopulmonary exercise test conducted approximately six weeks post-STEMI. Results indicated significant correlations between cardiac reserve metrics, such as stroke volume and cardiac output, and CRF measures, including peak oxygen uptake and ventilatory efficiency. The findings suggest that enhancing cardiac reserve may also improve CRF in this patient population.

Afoke, Jonathan; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, USA.
Stephens, Elizabeth H; Allison, Thomas G; Chopko, Trevor C; et al;

The Annals of thoracic surgery,2025 Oct 07

• Background: Optimum timing for surgery in asymptomatic/mildly symptomatic adult patients with Ebstein anomaly remains uncertain. This study assessed the association between pre-operative cardiopulmonary exercise testing (CPET) and mortality; and longitudinal changes in CPET.
• Methods: Retrospective review of consecutive adult patients with Ebstein anomaly who had tricuspid surgery between 2007 and 2018 with pre-operative CPET. Primary outcome was all-cause mortality and secondary outcome were changes in CPET.
• Results: The cohort included 116 patients. Ninety-four (81.1%) were NYHA Class I/II. Median age was 39.6 years and 75 (64.7%) were female. Forty-four (37.9%) had one or more prior sternotomies, 58 (50%) underwent Cone repair and 55 (47.5%) had tricuspid replacement. Median percentage predicted peak VO ₂ was 62% and ventilatory efficiency was 30 l/min/min. Fifteen (12.9%) had severe right ventricle dysfunction and median left ventricular ejection fraction was 58%. At median follow up of 9.8 years, there were 8 deaths. Ventilatory efficiency trended to be associated with mortality (p=0.075) on univariate analysis and was the largest contributor to prediction of mortality in machine learning Random Forest models. 33 patients had CPET at a median of 2.9 years after surgery. There was significant improvement in ventilatory efficiency (30 pre-operatively vs 27 l/min/l/min post-operatively, p=0.015).
• Conclusions: In those with minimal or no symptoms, ventilatory efficiency is one of the most important variables in predicting mortality after surgery. Patients may have improved ventilatory efficiency after tricuspid surgery for Ebstein anomaly. These findings highlight the role of CPET in optimizing timing of surgery.

Wilhite, Daniel P.; VA Airborne Hazards and Burn Pits Center of Excellence, East Orange, NJ.
Alexander, Thomas; Klein-Adams, Jacquelyn C.; Falvo, Michael J.

Medicine & Science in Sports & Exercise; (Baltimore, Maryland) 2025Supplement; v.57, 116-116. (1p)

he article focuses on a study comparing cardiorespiratory fitness and dyspnea on exertion (DOE) between deployed Veterans from post-9/11 conflicts and non-deployed controls. The study involved 25 deployed Veterans and 11 non-deployed controls who underwent cardiopulmonary exercise testing (CPET) using the Bruce treadmill protocol. Results indicated that deployed Veterans experienced significantly higher perceived breathlessness at peak exercise compared to controls, despite no significant differences in peak oxygen consumption (V̇O2peak). The findings suggest that DOE in deployed Veterans may not be solely due to deconditioning, highlighting the need for further research to explore underlying factors contributing to respiratory issues.

Beaven, Michael ;Curtin University, BENTLEY, Australia.
Brown, Henry; Wilson, Andrew; Gibbons, James; et al; 

Medicine & Science in Sports & Exercise; (Baltimore, Maryland) 2025Supplement; v.57, 114-115. (2p)

The article focuses on a study comparing cardiopulmonary exercise test (CPET) outcomes between preterm-born adults and term-born adults, specifically examining how different exercise modes (treadmill vs. cycle ergometry) affect physiological responses. The study involved 22 preterm-born adults (mean gestation: 27 weeks) and 5 term-born adults, who completed maximal CPETs on both exercise modes. Results indicated that preterm-born individuals had higher peak oxygen consumption (peak VO2) during treadmill tests compared to cycle ergometry, but the differences in exercise responses were similar for both groups. The findings suggest that cycle ergometry may underestimate peak VO2 in preterm-born individuals, which is important for interpreting exercise capacity assessments.

Tseng, Watson Hua-Sheng; Department of Medical Education, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
Chiu, Chien-Hung; Chang, Sing-Ya; Yang, Lan-Yan ;et al;

Annals of surgical oncology,2025 Oct 10

• Background: Cardiopulmonary exercise testing (CPET) parameters, such as ventilatory equivalent for carbon dioxide (V̇ _E /V̇CO ₂ ), peak oxygen consumption (V̇O _2peak ), and anaerobic threshold (AT), have been proposed as potential predictors of postoperative complications. Yet, few systematic analyses have examined the association between CPET variables and major complications after esophagectomy, as defined by the Clavien-Dindo classification. Associations with cardiopulmonary complications and mortality also require updating on the basis of trial sequential analysis (TSA).
• Materials and Methods: Systematic searches were conducted to identify relevant studies reporting preoperative CPET values and major complications, cardiopulmonary complications, and 1-year mortality. Standardized mean differences (SMD, random-effects model) were calculated and TSA was conducted to evaluate the robustness of evidence in the previous and current meta-analyses.
• Results: A total of 12 studies met inclusion criteria. V̇O _2peak was correlated with major complications (SMD = – 0.42; 95% CI – 0.70 to – 0.14, p = 0.0032) and cardiopulmonary complications (SMD = – 0.39; 95% CI – 0.65 to – 0.13, p = 0.0032). AT showed similar but weaker associations with both outcomes (SMD = – 0.33 and – 0.22; 95% CI – 0.63 to – 0.03 and CI – 0.40 to – 0.04, p = 0.033 and 0.018, respectively). V̇ _E /V̇CO ₂ demonstrated no meaningful relationship with major complications. In addition, the present study found neither V̇O _2peak nor AT was associated with 1-year mortality after esophagectomy.
• Conclusions: V̇O _2peak and AT were inversely associated with morbidity after esophagectomy, while V̇ _E /V̇CO ₂ offered limited prognostic value and none predict 1-year survival. V̇O _2peak is a key predictor of major and cardiopulmonary complications after esophagectomy and warrants further investigation, either alone or as part of a composite model.

Constantine A; Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
Dimopoulos K; McCabe C;

The European respiratory journal [Eur Respir J] 2025 Aug 22; Vol. 66 (2).
Date of Electronic Publication: 2025 Aug 22 (Print Publication: 2025).

Editorial comment.
No abstract available